➼

Blank Utah Driver License Application Form

The Utah Driver License Application form is a crucial document for residents seeking to obtain or renew their driver's license in the state of Utah. It gathers essential personal information, from basic details like name and date of birth, to more specific data concerning residency, legal status, and health conditions that could affect driving abilities. Completing this form accurately is vital, as it not only ensures compliance with state laws but also plays a part in safeguarding the roads for everyone.

Fill Out Your Document Online

Blank Utah Driver License Application Form

Article Structure

Navigating the Utah Driver License Application form can initially seem daunting, but understanding its components can demystify the process and set applicants on the right path to obtaining their license. This comprehensive form requires not only personal identification information such as full name, date of birth, social security number or Tax ID, and contact details, but it also extends to more specific data. Applicants must declare their legal status, consent for organ donation, veteran status, and whether they would like to register or preregister to vote, accentuating Utah's dedication to civic responsibilities alongside road safety. Further, the form delves into an applicant's driving history in other states or countries, any previous suspensions or revocations of licenses, and current medical conditions that could affect driving ability, illustrating a thorough vetting process aimed at ensuring that only qualified individuals take to Utah's roads. Additionally, offering options to contribute to charitable funds like “Friends for Sight” or the “Mobility Assistance Fund” highlights a community-focused spirit. With sections on medical certifications for commercial drivers and detailed queries about health conditions that might impact driving, the Utah Driver License Application form is designed not only to facilitate the licensing process but also to uphold public safety and welfare.

Form Preview Example

	UT LICENSE #					UT ID #

Full							________________________ ______
Legal _________________________ __________________________							________________________ ______
Name			Last			First		Middle		Suffix
Name
Date of Birth _____________________					Social Security Number or ITIN			__________________________
			mm/dd/yyyy		This information will not show on your driver license or ID card
UT Residence Address ___________________________________							_____________________			________
				Number/Street/Apartment				City		Zip Code
Mailing Address _________________________________ _____________________ ________										________
			PO Box/Number/Street/Apartment				City		State	Zip Code
Email Address _______________________________________________								Phone _____________________
Height _____FT. _____ IN.				Weight _______		Select		Select		Select
						Hair Color		Eye Color		Gender
Applicant’s						Mother’s
Place of		_______________________________________				Maiden ______________________			______________________
Birth			State/Country			Name	Last		First
NOTICE: APPLICANT MUST ANSWER ALL QUESTIONS.
	YES	NO	Are you a U.S. Citizen?
			YES	NO	Are you a legal permanent resident alien or a U.S. National?
			YES	NO	If you are a citizen of another country, do you have evidence of
					lawful presence in the United States?
	YES	NO	I would like to register my desire to help others by being an organ, eye, and tissue
			donor (life-saving anatomical gift.)

DLD Office Use Only:
EL LERN			ORG LERN
DPC	DL		CDL		ID	IDD
LTID	LTDL		LTCDL			MVP
Class:	A	B	C		D
End. H	N	X	Z P S T M
Visual Acuity:		Passed		Eye Statement
Restrictions:		A	B K	L	G	V 6
J:____________________
Motorcycle Restrictions:				2	3	5
Testing:	Written		Road		Ref/Asyl
				Translator: Y / N

Station Code: ___ Emp. #: ___ Initials: ___

Name Change:

From: _____________________________

To: _______________________________

ID #1: _____________________________

ID #2: _____________________________

Address Verified: ____________________

Full Legal Name:

__________________________________

DOB: __________ Iss Date: ___________

BC PP DHS #: ______________________

Iss. Agency: ________________________

YES NO

Are you a U.S. Military Veteran?

If yes, do you authorize sharing this information with the Utah Division of Veterans Affairs for the purpose of identifying veterans and disseminating veteran benefit information?

If you have been honorably discharged from the U.S. military, would you like to have a VETERAN indicator on your driver license or ID card? Provide a DD214 or Veterans Record/Notice of Separation indicating an honorable discharge.

Are you required to register as a sex offender with the State of Utah, any other state, or with the U.S. Government?

Have you ever been issued, a driver license by another state, country or province? If yes, list states/countries/provinces: ____________ # ____________ Exp. __________

If you are a CDL driver, have you been licensed in another state within the last 10 years? If yes, please list: _____ # ____________ I _____ # ____________

In the last 10 years, has your driving privilege been suspended, revoked, canceled, denied or disqualified? If yes, State: _____ # ____________

Why? _______________________________________________________________

Required Docs Scanned: YES

SSN: _______________ Date: __________

SAVE: Approved/Exp.: ________________

Emp. #: __________ Date: _____________

CDLIS: CSOR ADD DRIVER

PDPS:

SB:________________________________

License Surrender:	YES	NO
CDL:	YES	NO
IDC:	YES	NO

Iss.: _____________ Exp: _____________

State: ___________ End.: _____________

License #: __________________________

Total $: __________ Trans #: __________

Print the name of the person signing for minor: ___________________________________________

Father Mother Guardian

Initials: ______

Date Stamp: ________________________

YES	NO	Do you wish to contribute a $2.00 donation to the "Friends for Sight" fund?
YES	NO	Do you wish to contribute a $2.00 donation to educate people about organ, eye and
YES	NO	tissue donation?
		tissue donation?
YES	NO	Do you wish to contribute a $1.00 donation to the "Mobility Assistance Fund?"
YES	NO	Do you claim to be disabled under the Americans with Disabilities Act?
YES	NO	Do you claim to be indigent and are applying for an ID card for voting purposes?	DLD6a Rev. 5/18
YES	NO

UT LICENSE #UT ID #

Applicants who apply for or hold a license are responsible to report physical or mental health conditions to the division.

DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS IN THE LAST FIVE YEARS?

Diabetes:	YES	NO	Do you take insulin?
Cardiovascular:	YES	NO	Do you have an uncontrolled heart condition?
	YES	NO	Do you have an implantable cardioverter defibrillator (ICD)?
	YES	NO	Have you lost consciousness or fainted in the last five years?
Pulmonary:	YES	NO	Do you have a pulmonary (lung) condition?
Pulmonary:	YES	NO	Is an inhaler the only medication prescribed for this condition?
	YES	NO
	YES	NO	Do you use supplemental oxygen?
	YES	NO	Do you use supplemental oxygen?
Neurologic:	YES	NO	Do you have, or have you had a neurological condition such as: Dementia, strokes, Alzheimer's, traumatic brain
			injury, Multiple Sclerosis, or Parkinson's?
Epilepsy:	YES	NO	Do you have or have you had seizures in the last five years? Or,
	YES	NO Commercial Driver: Anytime during your life?
Learning &	YES	NO	Do you have learning and memory difficulties which may interfere with driving safety?
Memory:	YES	NO
Memory:
Mental Health	YES	NO	Do you have a mental health condition such as schizophrenia, severe anxiety, or severe depression?
Conditions:
Alcohol & Other	YES	NO	Do you use alcohol excessively, misuse prescription drugs, or use illegal drugs?
Drugs:	YES	NO	Have you been treated for alcohol or chemical dependency, or has treatment been recommended by a medical
			professional?
Vision:	YES	NO	Are you required to wear glasses or contact lenses for driving?
	YES	NO	Is your visual acuity worse than 20/40 in the better eye, even with corrective lenses?
	YES	NO	Do you have a degenerative or progressive eye condition?
	YES	NO	Have you experienced a decrease in peripheral (side) vision?
Musculoskeletal:	YES	NO	Do you have loss or paralysis of all or part of a limb, or severe arthritis?
	YES	NO	New or changed in the past 5 years?
	YES	NO	Present longer than 5 years?
Alertness or Sleep	YES	NO	Do you have a condition that produces abnormal sleepiness (sleep apnea, narcolepsy, etc.)?
Disorders:
Other:	YES	NO	Are there any other health problems or use of medications which might interfere with driving ability or safety or
Other:	YES	NO	control of a vehicle? Please explain:______________________________________________________________

Answering yes to any of the above questions may result in your receiving a request for additional follow-up information.

VOTER REGISTRATION
YES	NO	Do you authorize the use of information in this form for voter registration purposes?
YES	NO	Any voter may register as an absentee voter to receive ballots by mail. A voter may change this designation at any time. Would you like to be registered as an
		absentee voter to receive ballots by mail?
YES	NO	I would like to request that my voter registration record be classified as a private record.
Political Party:		Constitution	Democratic	Green	Independent American	Libertarian	Republican	United Utah	Unaffiliated	Other___________________

To register or preregister to vote in Utah, you must be a citizen of the United States, have resided in Utah for 30 days immediately before the next election, and not be a convicted felon currently incarcerated for a felony. You must be 16 or 17 years old to preregister to vote or at least 18 years old on or before the next general election to register to vote. If you decline to register to vote, the fact that you have declined will remain confidential and will be used only for voter registration purposes. If you register to vote, the office with whom you register will remain confidential. The portion of your voter registration form that lists your license or identification card number, social security number, email address, and the day of your month of birth is a private record. The portion of your voter registration form that lists your month and year of birth is a private record, the use of which is restricted to government officials, government employees, political parties, or certain other persons. In order to be allowed to vote in a voting precinct for the first time or to vote during the early voting period before the date of the election, you must present valid voter identification to the poll worker before voting as follows: (1) a valid form of photo identification that shows your name, photograph, and current address; or (2) two different forms of identification that show your name and current address.

CITIZENSHIP AFFIDAVIT/VOTER DECLARATION	DLD Office Use Only: Examiner Notes
CITIZENSHIP AFFIDAVIT/VOTER DECLARATION
I hereby swear and affirm, under penalties for voting fraud set forth in Utah Code Sec. 20A-2-401 that I am a citizen of the United States and
that to the best of my knowledge and belief the information I have given is true and correct. I do swear (or affirm), subject to penalty of law
for false statements, that the information contained in this form is true, and that I am a citizen of the United States and a resident of the State
of Utah, residing at the above address. Unless I have indicated that I am preregistering to vote in a later election, I will be at least 18 years of
age and will have resided in Utah for 30 days immediately before the next election. I am not a convicted felon currently incarcerated for
commission of a felony.
x___________________________________________ Date: ___________________
Sign ABOVE to register to vote.

UT LICENSE #	UT ID #

PLEASE STOP AND TAKE THE COMPLETED FORM TO AN EXAMINER

FAILURE TO TRUTHFULLY COMPLETE QUESTIONS MAY RESULT IN WITHDRAWAL OF DRIVING PRIVILEGE OR IDENTIFICATION CARD.

By submitting this application, I am consenting to registration with the Selective Service System, if required by federal law. Refusal to consent to the release of information to the Selective Service System shall result in the denial of the license and/or identification card.

Implied Consent - By operating a motor vehicle in this state you have given consent to a chemical test of your breath, blood, urine, or oral fluids for the purpose of determining if you are operating or in actual physical control of a motor vehicle while having a blood or breath alcohol content or are under the influence of drug or a combination of both that is prohibited by Utah law.

ID AFFIDAVIT: I, the undersigned, under penalty of perjury affirm that I am the applicant described on this application and that the information entered herein is true and correct to the best of my knowledge. I acknowledge cancellation and surrender to the Driver License Division, where possible, of any previously issued license certificates or ID cards.